by Chris Kenning and Laura Ungar, The (Louisville, Ky.) Courier-Journal

by Chris Kenning and Laura Ungar, The (Louisville, Ky.) Courier-Journal

LOUISVILLE, Ky. -- April Blevins was working as a bus driver in Bardstown, Ky., when severe bipolar disorder turned her life upside down in 2007.

She had to leave her job and couldn't get insurance for nearly a year. When she finally got insurance through her husband's employer, her coverage was limited to 30 days of psychiatric hospital care a year and no more than five days in a row.

"I felt like they'd push me out the door in five days, whether I was ready or not," Blevins said. "After that you just try to deal with it as best you can, because you can't afford it. But you suffer, and your family suffers."

In Kentucky, Indiana and across the nation, access to insurance and limits on services, therapy visits and hospital stays have left those with mental illness feeling treated like second-class citizens in a health system built to handle physical ailments, according to patients, providers and advocates.

"If you treated oncology like you do behavioral health, you'd have people rallying in the streets," said Tony Zipple, chief executive officer at Seven Counties Services, the Louisville area's largest mental health provider.

But under the Affordable Care Act, also known as "Obamacare," insurers will soon be required to give mental illness coverage equal to that for physical ailments.

Starting next year, the ACA calls for one of the largest expansions of mental health and substance abuse coverage in a generation, requiring that all new small-group and individual market plans offer mental health services and cover them at a par with medical benefits.

Federal officials estimate that the ACA will extend parity protection to nearly 30 million people in individual and small-group plans and offer insurance with mental health coverage to another 32 million previously uninsured Americans.

"It's going to be a huge change. It's really going to level the playing field between mental health and physical health," said Cathy Epperson, president of the National Association of Mental Illness of Kentucky. "I think recovery will improve because more people will get the help they need."

Advocates hope the change will close most of the loopholes and gaps in previous attempts to legislate parity - including a Kentucky law passed in 2000 and a federal 2008 law that applied only to large-group plans - and mark a milestone toward better treatment for mental illness.

But some health care and state leaders remain skeptical that the ACA will solve all of the treatment problems those with mental illness face.

"Insurance companies can always find a way to put up barriers, whether you make laws or not," said Democratic state Rep. Mary Lou Marzian of Louisville.

Long-standing limits

Sheila Schuster, executive director of the advocacy group the Kentucky Mental Health Coalition, said most people would object to a policy saying "you only get 10 days of chemotherapy treatments a year." But such limits have been a chronic issue with mental health care because of disagreements over what constitutes necessary care.

"When a patient presents when they come in for a broken arm or cancer, it's easier to see it and to know what's needed to treat it. But it's much different with mental illness," said Republican state Sen. Julie Denton of Louisville, a parity advocate. "In many instances it's a long, drawn out course of treatment, maybe over a lifetime. So it can be very expensive, and it's harder to say what's medically necessary."

As a result, insurance often provides adequate coverage for relatively brief mental-health treatment, such as for those battling depression following the death of a loved one, but not for serious long-term mental illness, said Ramona Johnson, CEO of BridgehavenMental Health Services in Louisville.

Insurance, she said, is typically "set up to cover physical illness."

For instance, she said some plans limit hospitalization or constrain outpatient therapy sessions to 12 or 20 a year. Other providers said some plans also require higher co-insurance or deductibles for mental health care visits.

As result, even those with insurance find it hard to get the care they need for their mental illness, Zipple said.

"If you don't have a lot of cash, and you have to figure out, 'Am I going to put food on the table or am I going to get a prescription for my depression,' you are more often than not going to choose to put food on the table," he said.

Complicating matters, Zipple said, people sometimes see mental health treatment as something they can skip until their financial picture improves.

"Often," he said, "people see depression or anxiety as something they can handle on their own."

In some cases, those issues combine to disastrous effects.

Last summer, friends began noticing that Todd Hiett, a 43-year-old massage therapist, was growing delusional and manic. Urged to seek help, Hiett checked himself into a Lexington psychiatric hospital and was diagnosed with bipolar disorder.

Like Blevins, Hiett's insurance capped his stay at five days. He was released and given a prescription for anti-psychotic medication, but didn't take it because he believed he didn't need it. Within weeks, Hiett said he had a psychotic episode that resulted in him breaking the law and landing in jail.

Eventually, he couldn't afford to pay his premium, lost his insurance and now lives in Paducah, Ky., with his mother.

He said he's not certain whether a longer stay would have helped, but believes that mental and physical coverage should be put on equal footing.

Dr. LaQuandra Nesbitt, director of the Louisville Metro Department of Public Health and Wellness, said parity is difficult to determine because "it's so ambiguous."

In some cases, Nesbitt said, some insurers limited mental health by placing new requirements for pre-authorizations, on physical health coverage.

Robert Zirkelbach, spokesman for the trade group America's Health Insurance Plans, acknowledged that limits exist in some cases - for both mental and physical health - and said coverage decisions are based on medical necessity. He disputed the contention that insurers were seeking "loopholes" in parity laws.

"That's a pretty general thing to throw out there," Zirkelbach. "Plans work hard to achieve parity."

For example, Gannon said, Medicaid used to cover unlimited outpatient visits without authorization, and now there are authorization requirements.

"They're imposing the same limits private insurance is," she said.

Kissner acknowledged that authorizations rankle providers and clients, and managed-care companies are far more likely to turn down authorization requests. Under managed care, denials are up to around 7 percent, compared with 1 percent previously.

Promise and concern

Starting in January as part of the Affordable Care Act, all new plans must pay for mental, behavioral and substance abuse services - which many advocates say should move the nation closer to parity between mental and physical health coverage.

Rachel Garfield, a senior researcher with Kaiser Family Foundation, said, cost-sharing rules and service limits must be the same. For instance, if there's a 10-visit limit for psychiatrist visits, there must also be a 10-visit limit for primary care physicians.

She noted that these rules apply only to new plans. This year, 36 percent of covered workers are in a grandfathered health plan that is exempt from requirements of the new law, and Garfield said, "the jury's still out if plans can maintain grandfather status."

The law's mental health coverage is "an opportunity for a lot of people who may have had no coverage to be able to get it," Nesbitt said.

That will include people like Hiett, who says he may seek coverage on Kentucky's health benefit exchange that opens for enrollment Oct. 1.

Insurance companies declined to comment for this story. But Zirkelbach said many insurance plans are working to help consumers by coordinating care and helping them navigate the system.

"The overall message is that more people will have coverage for mental and behavioral health treatment than they have today," he said.

If more people get mental health coverage, Zirkelbach said, that will improve physical health as well, since they are "oftentimes inextricably linked." For instance, depression has been linked to heart disease, stroke and other ailments.

But several mental health providers said there's no guarantee that the ACA will achieve equality between mental and physical health coverage.

"I don't know if it will actually bring parity. It will depend on how the (insurance) plans are written," Johnson said. "It's definitely a step in the right direction."